Delaware's Journey in Adopting Telehealth

Delaware’s Journey in Adopting Telehealth  Carolyn Morris, MHSA, CTPM; Ingrid Pretzer-Aboff, PhD, RN; Gerard Gallucci, MD, MHS

Introduction

The first telehealth application is generally credited to the use of closed-circuit television in a Nebraska psychiatric hospital in 1959 for training medical students who observed patients at a distance.1 However, in 1948 the first radiology images were sent 24 miles via telephone lines between two points in eastern Pennsylvania.2 And telehealth was envisioned much earlier. The invention of the radio had led to a world of ideas for its use, including uses for health care. For instance, in 1925, German scientist Hugo Gernsback designed a theoretical device for telemedicine that would use radio waves to allow doctors to see their patients through a view screen and examine them from miles away using his radio-controlled “teledactyl;” he anticipated it would be in use by 1975. (See Figure 1).3

Due to geographic constraints in remote areas, like Antarctica and Alaska, and the need to bridge those distances to deliver health care, telehealth has been in use for more than 50 years. In the early 1960s, space exploration made the transmission of health information of astronauts from space to physicians on earth a necessity.2 Telehealth has been especially beneficial in prisons and other corrections situations to reduce costs and improve safety for staff as well as the public, with programs operational in the US since the 1990s.2 In 2002, the first telemedicine surgery was performed at the South Pole4 with assistance from orthopedic surgeons at Massachusetts General Hospital in Boston. Today, telehealth has become an essential tool for providing health care to individuals of all ages, especially in rural areas and areas of professional shortage. But with the silver tsunami upon us, there is a need to improve access to health care in all geographic locations. There are dozens of federal and state definitions of telehealth.5 According to the Health Resources and Services Administration (HRSA), “Telehealth is defined as the use of electronic information and telecommunication technologies to support and promote longdistance clinical health care, patient and professional health-related education, public health, and health administration.”6 The many definitions dictate how policies are written that impact the use of telehealth at federal and state levels. However, there are four general ways telehealth is used: • Live, real time video conferencing (synchronous) between a person and a health care professional which may involve direct

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evaluation and treatment or consultation between professionals; • Store-and-forward (asynchronous) transmission of recorded health information, such as x-rays or other images, for evaluation and/or treatment that will take place sometime afterward; • Remote patient monitoring (RPM) to collect and transmit data (telemetry) from a person at one location to a health professional at another location via electronic communication technologies; • Mobile health (mHealth) using devices such as cell phones and tablets to provide health care, public health services, or education. • The distinction between telehealth and telemedicine is, while telemedicine is usually thought of as the use of live, interactive videoconferencing between health professional and patient, telehealth includes all four of the above listed categories of applications, including telemedicine.5

BACKGROUND Telehealth was not much more than a blip on Delaware’s radar screen until late 2010. A couple of little-known uses of technology to provide care were already in operation locally but, for the most part, few physicians or consumers were paying attention to the benefits that technology could provide in improving access to health care in the state. Two key events helped catalyze telehealth in the state: A group of Delaware residents with Parkinson’s disease (PD) and their caregivers who were struggling to keep up with the trek to see specialists in urban locations, such as Baltimore7 and Philadelphia,8 learned about a specialist — known as a Movement Disorder Specialist (MDS) — who offered these specialty services via telemedicine;9 and The United States Department of Justice (DOJ) legal proceedings against the State of Delaware10 to resolve serious deficiencies in caring for individuals with serious and persistent mental health issues prompted exploration into ways to reduce institutionalization while meeting the mental health care needs of these individuals in the community.

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Telehealth became a potential solution. Members of the PD community approached then-Secretary of Health and Social Services, Rita Landgraf, to appeal for assistance in bringing MDS telemedicine services to Delaware. In response to this appeal, a group of about a dozen representatives from Delaware Department of Health and Social Services (DHSS), University of Delaware (UD), Sen. Thomas Carper’s office, and the PD community convened in March 2011 to explore how to further the use of telehealth in the state. Barriers to implementing telehealth in Delaware were identified and potential solutions were discussed. For example, it was immediately evident that Delaware Medicaid did not reimburse for telehealth, Medicare reimbursed for services delivered via telemedicine only under certain narrow criteria, and questions around private insurance reimbursement in Delaware needed answering. Many issues needed to be resolved; thus, the Delaware Telehealth Coalition was formed.

PARKINSON’S SPECIALTY SERVICES Concurrent to the formation of the Delaware Telehealth Coalition, leaders in the PD community approached associate professor Dr. Ingrid Pretzer-Aboff, at the UD School of Nursing to help recruit the services of PD specialists to the state. Seeking to understand the need and scope of the problem, a survey was conducted

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among PD support groups across Delaware. Results confirmed that approximately 50 percent of support group members with PD drove out of the state for specialty care, with the majority traveling to Baltimore and Philadelphia Movement Disorder Centers. The remaining group members did not make the trip out of state as it was “too burdensome.” With the estimated 3,000-plus people on the Delmarva Peninsula diagnosed with Parkinson’s disease, there was a clear need to import PD specialists into the state. A feasible solution to the problem was to utilize telehealth technology to access a movement disorder specialist and a clinical psychologist. In 2013, the process of developing the clinic model began. Efforts were made to identify local nurse practitioners, physical therapists, speech and language pathologists, occupational therapists, nutritionists, exercise physiologists with expertise in PD, and to identify an out of state movement disorder specialist (MDS) and a clinical psychologist with expertise in PD and telehealth. The out of state specialists needed to obtain professional licenses in the state of Delaware, and the institutions they worked in needed to develop a working contract with UD, a process that took more than one year to execute. The videoconferencing equipment was purchased and installed with financial support from the UD College of Health Science, Delaware Health and Social Services Division of Services for Aging and Adults with Physical Disabilities (DSAAPD), and The Parkinson Council. The Director of the UD Nurse Managed Primary Care Clinic (NMPCC) agreed to host this new clinic twice

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per month and provided the necessary personnel, infrastructure, and space. On March 13, 2014, the Nurse Managed Parkinson’s Clinic (NM-PD Clinic) accepted their first PD patients. The clinic used a hybrid model with a mix of telehealth and face-to-face interactions all taking place in the same location. In this model, the nurse practitioner meets first with each PD patient and then introduces the patient to the MDS on a large monitor screen set on top of a telehealth cart. This multidisciplinary team model is a powerful way to provide health care. Telehealth technology allows for this model of care to be delivered anywhere. Since its inception the patient satisfaction rates have been very high, and as word has spread about the PD clinic, the wait list has grown to be 4-6 months long, necessitating the need to bring in a second movement disorder specialist from out of state to help see the volume of new patients. Three years after the opening of this part-time clinic, more than 250 new patients have been seen. While the model works extremely well, the one barrier to its sustainability is the lack of Medicare reimbursement for telehealth. The overwhelming majority of patients with Parkinson’s disease are over the age of 65 and, as such, do not have insurance coverage for telehealth visits. The short term solution for this problem in this academic setting is to cover the cost of the telehealth specialists using grant funding and foundation support. Leaders in the Parkinson’s community are actively involved at the state level to resolve this issue at the legislative level.

BEHAVIORAL HEALTH SERVICES The behavioral health clinical community in Delaware has been gradually implementing telehealth for mental/behavioral health services; commonly used terms for these services include telepsychiatry, telemental health, telebehavioral health, and telepractice. Telepsychiatry is critical due to the shortage of psychiatrists and the need for prescribers, particularly in Sussex County.11 Use cases of telepsychiatry include on-call services at Delaware Psychiatric Center (DPC), medication assisted treatment (MAT) programs for opioid addiction licensed through the Division of Substance Abuse and Mental Health (DSAMH), crisis intervention, and screening and treatment services for depression and other behavioral health conditions. Telehealth for counseling or therapy services is expanding, as well. Drug and alcohol counseling, family therapy, and psychology services are becoming available; a somewhat slower adoption,

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however, may be due to the wait for regulatory guidance recently finalized in these professions as well as reimbursement issues. Children and adults can benefit from such services, but the Medicare population (i.e., seniors and individuals with disabilities) has few options due to the lack of Medicare reimbursement for telehealth anywhere in the state. (Reimbursement is discussed in more detail below.)

DELAWARE TELEHEALTH COALITION As previously mentioned, the Delaware Telehealth Coalition was formed in response to the need to cultivate the use of telehealth in the state. It was clear from the start that many local health care professionals and consumers knew little about telehealth except for a few programs already in operation including the eICU at Christiana Care Health System (CCHS), the CCHS Visiting Nurses Association (VNA) use of remote patient monitoring (RPM) for its home health program, and Nemours AI DuPont Hospital for Children (Nemours) use of store and forward technology for physician-tophysician cardiology consultations. The coalition provides education, collaboration, and networking. Coalition member organizations have partnered on projects, shared policy and technical information with each other, and addressed barriers and challenges together. One member — from the PD community — knocked on legislators’ doors until champions for telehealth surfaced and sponsored HB 69 (aka the telemedicine bill) which mandated private insurance reimbursement. Governor Jack Markell signed the bill into law wand it became effective January 1, 2016.12 Unfortunately, after all of their efforts, the law does not do much to benefit the PD community since most people with PD are covered by Medicare. The coalition continues to advocate for Medicare coverage by way of writing letters to (and having conversations with) federal officials, as well as by exploring the relationship of telehealth with new payment models such as those for the various types of Accountable Care Organizations (ACOs). Other progress in advancing telehealth in the state since that first meeting in 2011 includes: the 2013 Delaware Telehealth Roundtable and the resulting 2014-2016 Telehealth Strategic Action Plan (SAP), the implementation of the SAP, and a new roundtable to refresh the plan in May 2017; the October 2015 Telehealth in Delaware Conference, a partnership between the coalition, DHSS and the University of Delaware’s Division of Professional and Continuing Studies (PCS), attended by over 165 stakeholders; and the creation of a position within DHSS to manage telehealth projects within the department, to serve as a local resource on

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issues related to telehealth to local stakeholders and to coordinate coalition activities. Conference surveys revealed a strong interest for further training and, in response, PCS developed the Advanced Telehealth Coordinator certificate program. Additionally, various organizations have embarked on implementing telehealth in areas such as remote patient monitoring, telemental health and substance use disorder services, telemedicine for specialty care, and increased use of direct-to-consumer primary care telehealth products being offered to employees and health insurance subscribers in the hope of reducing unnecessary trips to emergency departments.

CHALLENGES Despite the progress, some significant challenges remain. Telehealth is still viewed as relatively new to some Delaware physicians who cannot envision how they can use telehealth in their particular discipline and to some consumers not yet familiar with it. Yet telehealth has been around in other states such as Virginia, Alaska, California, and West Virginia, to name a few, for more than 20 years. The state’s proximity to urban academic medical centers, where many subspecialties and centers of excellence are concentrated, made access to care seem adequate at one time, delaying any obvious need for telehealth. In contrast, variables such as distance, age, lack of mobility or transportation, today’s Delaware consumers need alternative options to driving out of state for specialized care. The need is there, but demand depends on perspective and buy-in (i.e., doctor, patient, or caregiver). The coalition strives to provide outreach to the community, to raise awareness about the benefits of telehealth and to increase physician and consumer buy-in. Where reimbursement was not widely available until passage of HB 69 and Medicaid expansion of coverage in 2015, better financial opportunities may encourage some physicians to develop telehealth programs. However, as previously noted, lack of Medicare reimbursement for telehealth in Delaware discourages some physicians from adopting telehealth as a service delivery tool. This applies to not only those physicians who strictly treat seniors, but also to clinicians who treat multiple age groups such as primary care and behavioral health professionals because they may not be willing to carve out separate services and billing processes based on payer. To add a positive, albeit complex, note, individuals with both Medicare and Medicaid may be candidates for certain telehealth services; Delaware Medicaid has indicated it will reimburse for Medicaid-covered services for dually eligible (i.e., with both Medicare and Medicaid) individuals if a proper denial is obtained from Medicare. Additionally, though HB 69 mandated private insurance parity, large self-insured employers protected

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under the Employee Retirement Income Security Act (ERISA) are not required to adhere to state insurance reimbursement mandates.13 Fortunately, many of these large self-insured employers are reportedly following most, if not all, of the elements of the law. When a law is passed, regulations often follow. A number of state regulations related to telehealth are in various stages of promulgation from medicine to allied health and even dentistry. Some proposed regulations went through several iterations prior to finalization, and some even drew the attention of outside agencies which commented on several proposed regulations. One of the benefits of the coalition is the ability to disseminate information about regulatory and legislative activity in case members have a stake in the outcome of these policies, prompting some stakeholders comment at public policy hearings. This activism may have helped to educate some regulatory board members about the benefits of telehealth and in other cases may have helped streamline the regulatory process.

DELAWARE LANDSCAPE In addition to the earliest uses of telehealth in Delaware at CCHS and Nemours, and, later, UD NMPCC’s Parkinson’s disease telehealth clinic, the number of use cases is growing. Telepsychiatry has been implemented at organizations such as Beebe Healthcare, Mid-Atlantic Behavioral Health, and Connections. Remote patient monitoring is being used at more home health agencies such as Bayada, along with the integration of video conferencing with specialists during home health visits. Teleneurology has been implemented at CNMRI and Bayhealth conducted a telestroke pilot. And, today, Nemours boasts a growing portfolio of dozens of telehealth service lines from emergency room consults to weight management services, behavioral services, and more. Additionally, Project ECHO (Extensions for Community Health Outcomes), a program of combined didactic and case review services for primary care clinicians, has been utilized at one or more community clinics for pain management and medication assisted treatment for opioid addiction.14 Project ECHO, “links expert specialist teams at an academic ‘hub’ with primary care clinicians in local communities — the ‘spokes’ of the model.”14  

THE FUTURE Strategic planning activities identified key priorities, objectives, and action items. Implementation of the first SAP was successful despite limited resources (funds); everyone who worked on the

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various implementation committees volunteered to help on behalf of their respective organizations or as consumers and caregivers. Progress related to telehealth in areas of policy, reimbursement, and workforce development is noteworthy. More needs to be done, but the coalition has begun reaching out to the next generation of health care professionals by working with the Department of Education (DOE) to introduce the topic of telehealth to high school students interested in careers in the health professions starting with workshops at the Delaware HOSA — Future Health Professionals State Leadership Conference (SLC). This was an excellent first opportunity to introduce the topic of telehealth at the secondary school level in an effort to engage students to envision how technology can be a tool for delivering health care. As future health care professionals advance to post-secondary training and education, the hope is that the use of technology in the delivery of health care will be securely ingrained in their minds as they learn to address challenges in meeting the health care needs of individuals across all populations. Additional educational opportunities are being discussed with DOE to include students in areas such as the public and community health curriculum, health care information technology curriculum, and general information technology curriculum. Stakeholders identified new objectives during the recent 2017 Delaware Telehealth Roundtable where strategic planning revealed the need for additional workforce development opportunities, billing workshops, guidelines, standards, and outreach to increase the exposure of telehealth to clinicians statewide. Of course, reimbursement issues with Medicare and large, self-insured employers (along with new payment models) on the horizon are at the top of the list. This new strategic plan is still being developed, but with the engagement of so many talented and dedicated health care professionals and advocates, the state is destined for success.

CONTRIBUTING AUTHORS ■ CAROLYN MORRIS, MHSA, CTPM is Director of Telehealth Planning and Development at the Delaware Department of Health and Social Services and Co-Chair of the Delaware Telehealth Coalition. She also represents Delaware on the Mid-Atlantic Telehealth Resource Center’s Advisory Borad. ■ INGRID PRETZER-ABOFF, PhD, RN is Co-Founder and Director of the University of Delaware Nurse Managed Parkinson’s Clinic. In 2010 she received the first Edmond J. Safra Philanthropic Foundation Distinguished Scholar in Nursing Award for Outstanding Achievement in Improving the Lives of People Living with Parkinson’s Disease. ■ GERARD GALLUCCI, MD, MHS is Director of Healthcare Integration at the Delaware Department of Health and Social Services and Co-Chair of the Delaware Telehealth Coalition.

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REFERENCES 1. Ramos V. Contributions to the History of Telemedicine of the TICs. 2010 Second Region 8 IEEE Conference on the History of Communications. 2010. 2. Institute of Medicine (US) Committee on Evaluating Clinical Applications of Telemedicine; Telemedicine: A Guide to Assessing Telecommunications in Health Care. Field, MJ, ed., Washington, DC: National Academies Press; 1996. 2, Evolution and Current Applications of Telemedicine. Available at: https://www.ncbi.nlm. nih.gov/books/NBK45445/ 3. N ovak M. Telemedicine Predicted in 1925. Smithsonian. com. Available at: http://www.smithsonianmag.com/history/ telemedicine-predicted-in-1925-124140942/. Published March 14, 2012. Accessed May 19, 2017. 4. ‘Telemedicine’ Operation Performed at South Pole. USA Today. Available at: http://usatoday30.usatoday.com/news/science/coldscience/2002-07-17-pole-operation.htm. Published July 7, 2002. Accessed May 20, 2017. 5. W hat is Telehealth? Center for Connected Health Policy. Available at: http://www.cchpca.org/what-is-telehealth. Accessed March 4, 2017. 6. W hat is Telehealth? HealthIT.gov. Available at: https://www.healthit.gov/telehealth. Accessed May 22, 2017. 7. T he Parkinson’s Disease and Movement Disorders Center at Johns Hopkins in Baltimore, MD. Johns Hopkins Medicine. Available at: http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_ clinics/movement_disorders/. Accessed March 4, 2017. 8. M  ovement Disorders – Penn Medicine. Penn Medicine. Available at: https://www.pennmedicine.org/for-patients-and-visitors/finda-program-or-service/neurology/movement-disorders. Accessed March 4, 2017. 9. Telemedicine Brings Parkinson’s Care to “Anyone, Anywhere”. University of Rochester Medical Center. Available at: https:// www.urmc.rochester.edu/news/story/3977/telemedicine-bringsparkinsons-care-to-anyone-anywhere.aspx. Published December 4, 2013. Accessed March 4, 2017. 10. In the United States District Court for the District of ... The United States Department of Justice. Available at: https://www. justice.gov/sites/default/files/crt/legacy/2011/07/06/DE_ settlement_7-6-11.pdf. Published July 6, 2011. Accessed March 4, 2017. 11. Toth T. Mental Health Professionals in Delaware, 2014. Division of Public Health - Delaware Health and Social Services. Available at: http://dhss.delaware.gov/dhss/dph/hsm/files/mhpinde2014.pdf. Published October 2014. Accessed May 23, 2017. 12. House Bill 69 | 148th General Assembly. Bill Detail - Delaware General Assembly. Available at: https://legis.delaware.gov/ BillDetail/24232. Published July 7, 2015. Accessed March 11, 2017. 13. K aminski JL. Self-Insured Benefit Plans and Insurance Mandates. Available at: https://www.cga.ct.gov/2005/rpt/2005-R-0753.htm. Published October 3, 2005. Accessed March 12, 2017. 14. A  Revolution in Medical Education and Care Delivery. Project ECHO. Available at: http://echo.unm.edu/. Accessed May 25, 2017.

Del Med J | July 2017 | Vol. 89 | No. 7